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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022https:\/\/adc.bmj.com\/sites\/default\/files\/advagg_css\/css__ZqR9oFtEjI7t5h7UPJpE0tHpaVSMTAbm0a23YsPXKOs__B1XXDfhmSao7iMSBpHmKHU-2Vt_ayuu11HDPZxWgMF8__EiRMLAPv5f7gKxYfRklz5KLyeKyYiCmb0byjpP19Xu4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-jnl-template-bmjj-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup author-affiliates col-narrow-12 author-affiliates-corresp article\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 class=\u0022contributors\u0022\u003E\u003Col class=\u0022contributor-list\u0022 id=\u0022contrib-group-1\u0022\u003E\u003Cli id=\u0022contrib-1\u0022\u003E\u003Cspan class=\u0022name\u0022\u003ED A Lawlor\u003C\/span\u003E\u003Ca id=\u0022xref-aff-1-1\u0022 class=\u0022xref-aff\u0022 href=\u0022#aff-1\u0022\u003E1\u003C\/a\u003E, \u003C\/li\u003E\u003Cli id=\u0022contrib-2\u0022\u003E\u003Cspan class=\u0022name\u0022\u003EA A Mamun\u003C\/span\u003E\u003Ca id=\u0022xref-aff-2-1\u0022 class=\u0022xref-aff\u0022 href=\u0022#aff-2\u0022\u003E2\u003C\/a\u003E, \u003C\/li\u003E\u003Cli id=\u0022contrib-3\u0022\u003E\u003Cspan class=\u0022name\u0022\u003EM J O\u2019Callaghan\u003C\/span\u003E\u003Ca id=\u0022xref-aff-3-1\u0022 class=\u0022xref-aff\u0022 href=\u0022#aff-3\u0022\u003E3\u003C\/a\u003E, \u003C\/li\u003E\u003Cli id=\u0022contrib-4\u0022\u003E\u003Cspan class=\u0022name\u0022\u003EW Bor\u003C\/span\u003E\u003Ca id=\u0022xref-aff-3-2\u0022 class=\u0022xref-aff\u0022 href=\u0022#aff-3\u0022\u003E3\u003C\/a\u003E, \u003C\/li\u003E\u003Cli id=\u0022contrib-5\u0022\u003E\u003Cspan class=\u0022name\u0022\u003EG M Williams\u003C\/span\u003E\u003Ca id=\u0022xref-aff-2-2\u0022 class=\u0022xref-aff\u0022 href=\u0022#aff-2\u0022\u003E2\u003C\/a\u003E, \u003C\/li\u003E\u003Cli id=\u0022contrib-6\u0022\u003E\u003Cspan class=\u0022name\u0022\u003EJ M Najman\u003C\/span\u003E\u003Ca id=\u0022xref-aff-2-3\u0022 class=\u0022xref-aff\u0022 href=\u0022#aff-2\u0022\u003E2\u003C\/a\u003E\u003Cspan class=\u0022xref-sep\u0022\u003E,\u003C\/span\u003E\u003Ca id=\u0022xref-aff-4-1\u0022 class=\u0022xref-aff\u0022 href=\u0022#aff-4\u0022\u003E4\u003C\/a\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Col class=\u0022affiliation-list\u0022\u003E\u003Cli class=\u0022aff\u0022\u003E\u003Ca id=\u0022aff-1\u0022 name=\u0022aff-1\u0022\u003E\u003C\/a\u003E\u003Caddress\u003E\u003Csup\u003E1\u003C\/sup\u003EDepartment of Social Medicine, University of Bristol, UK\u003C\/address\u003E\u003C\/li\u003E\u003Cli class=\u0022aff\u0022\u003E\u003Ca id=\u0022aff-2\u0022 name=\u0022aff-2\u0022\u003E\u003C\/a\u003E\u003Caddress\u003E\u003Csup\u003E2\u003C\/sup\u003ESchool of Population Health, University of Queensland Medical School, Brisbane, Australia\u003C\/address\u003E\u003C\/li\u003E\u003Cli class=\u0022aff\u0022\u003E\u003Ca id=\u0022aff-3\u0022 name=\u0022aff-3\u0022\u003E\u003C\/a\u003E\u003Caddress\u003E\u003Csup\u003E3\u003C\/sup\u003EChild Development and Rehabilitation Services, Mater Children\u2019s Hospital, Brisbane, Australia\u003C\/address\u003E\u003C\/li\u003E\u003Cli class=\u0022aff\u0022\u003E\u003Ca id=\u0022aff-4\u0022 name=\u0022aff-4\u0022\u003E\u003C\/a\u003E\u003Caddress\u003E\u003Csup\u003E4\u003C\/sup\u003ESchool of Social Science, University of Queensland, Brisbane, Australia\u003C\/address\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003Col class=\u0022corresp-list\u0022\u003E\u003Cli class=\u0022corresp\u0022 id=\u0022corresp-1\u0022\u003E\u003Cspan class=\u0022corresp-label\u0022\u003E\u003C\/span\u003ECorrespondence to:\u003Cbr\/\u003E Dr D A Lawlor\u003Cbr\/\u003E Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK; \u003Cspan class=\u0022em-link\u0022 title=\u0022d.a.lawlor@bristol.ac.uk\u0022\u003E\u003Cspan class=\u0022em-addr\u0022\u003Ed.a.lawlorbristol.ac.uk\u003C\/span\u003E\u003C\/span\u003E\u003C\/li\u003E\u003C\/ol\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article abstract-view\u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003EAbstract\u003C\/h2\u003E\n \u003Cp id=\u0022p-1\u0022\u003E\u003Cstrong\u003EAims:\u003C\/strong\u003E To examine the associations between being overweight and behavioural problems at ages 5 and 14.\u003C\/p\u003E\n \u003Cp id=\u0022p-2\u0022\u003E\u003Cstrong\u003EMethods:\u003C\/strong\u003E Birth cohort study of 2875 individuals who were born in Brisbane between 1981 and 1984 and who were followed up at ages 5 and 14 years. Behavioural problems were defined as scoring above the 90th centile on Achenbach\u2019s child behavioural checklist.\u003C\/p\u003E\n \u003Cp id=\u0022p-3\u0022\u003E\u003Cstrong\u003EResults:\u003C\/strong\u003E In cross-sectional analyses there was no association between being overweight and behavioural problems in either females at age 5. At age 14 females who were overweight were more likely than those who were normal weight to experience behavioural problems. However, there was no association between being overweight and behavioural problems at age 14 among males. The prevalence of behavioural problems increased linearly across the distribution of body mass index in females at age 14. In prospective analyses, among participants who had no behavioural problems at age 5, there was no association between being overweight at age 5 and behavioural problems at age 14 in either sex. Females who were overweight at age 5 and normal weight at age 14 had reduced odds of behavioural problems at age 14.\u003C\/p\u003E\n \u003Cp id=\u0022p-4\u0022\u003E\u003Cstrong\u003EConclusions:\u003C\/strong\u003E Among adolescent females there is a positive linear association between body size and behavioural problems. However, no such association was found in adolescent males, or in either sex at age 5 years, and in prospective analyses being overweight at age 5 was not associated with behavioural problems in either sex at age 14.\u003C\/p\u003E\n \u003C\/div\u003E\u003Cul class=\u0022kwd-group KWD\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Ebehavioural problems\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ebody mass index\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecohort study\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eoverweight\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Ca href=\u0022https:\/\/adc.bmj.com\/content\/90\/7\/692.full\u0022 class=\u0022hw-link hw-link-article-full-text\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Full Text\u003C\/a\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-dfp-pane oas-ads oas-ads-mid pull-right\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv id=\u0022dfp-ad-mpu-wrapper\u0022 class=\u0022dfp-tag-wrapper\u0022\u003E\n\n\u003Cdiv id=\u0022dfp-ad-mpu\u0022 class=\u0022dfp-tag-wrapper\u0022\u003E\n \u003Cscript type=\u0022text\/javascript\u0022\u003E\n googletag.cmd.push(function() {\n googletag.display(\u0022dfp-ad-mpu\u0022);\n });\n \u003C\/script\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-custom pane-1\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cp\u003E\u003Ca href=\u0022http:\/\/dx.doi.org\/10.1136\/adc.2004.062919\u0022 target=\u0022_new\u0022\u003Ehttp:\/\/dx.doi.org\/10.1136\/adc.2004.062919\u003C\/a\u003E\u003C\/p\u003E\n \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-altmetrics\u0022 \u003E\n \n \u003Ch2 class=\u0022pane-title\u0022\u003EStatistics from Altmetric.com\u003C\/h2\u003E\n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv data-badge-details=\u0022right\u0022 data-badge-type=\u0022medium-donut\u0022 data-doi=\u002210.1136\/adc.2004.062919\u0022 data-hide-no-mentions=\u0022true\u0022 class=\u0022altmetric-embed\u0022\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-bmjj-jumplinks\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022highwire-list-wrapper\u0022\u003E\u003Cdiv class=\u0022highwire-list\u0022\u003E\u003Cul\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view\u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cul class=\u0022kwd-group KWD\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003E\u003Ca href=\u0022\/search\/%20text_abstract_title%3Abehavioural%2Bproblems%20text_abstract_title_flags%3Amatch-phrase%20sort%3Apublication-date\u0022 class=\u0022hw-term hw-article-keyword hw-article-keyword-behavioural-problems\u0022 rel=\u0022nofollow\u0022\u003Ebehavioural problems\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003E\u003Ca href=\u0022\/keyword\/body-mass-index\u0022 class=\u0022hw-term hw-article-keyword hw-article-keyword-body-mass-index\u0022 rel=\u0022nofollow\u0022\u003Ebody mass index\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003E\u003Ca href=\u0022\/keyword\/cohort-study\u0022 class=\u0022hw-term hw-article-keyword hw-article-keyword-cohort-study\u0022 rel=\u0022nofollow\u0022\u003Ecohort study\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003E\u003Ca href=\u0022\/keyword\/overweight\u0022 class=\u0022hw-term hw-article-keyword hw-article-keyword-overweight\u0022 rel=\u0022nofollow\u0022\u003Eoverweight\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n \n \u003Cp id=\u0022p-5\u0022\u003EThe population prevalence of childhood obesity has increased by about threefold in most industrialised countries over the last 10\u201320 years.\u003Ca id=\u0022xref-ref-1-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-1\u0022\u003E\u003Csup\u003E1,\u003C\/sup\u003E\u003C\/a\u003E\u003Ca id=\u0022xref-ref-2-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-2\u0022\u003E\u003Csup\u003E2\u003C\/sup\u003E\u003C\/a\u003E These trends are likely to have major public health consequences.\u003Ca id=\u0022xref-ref-1-2\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-1\u0022\u003E\u003Csup\u003E1,\u003C\/sup\u003E\u003C\/a\u003E\u003Ca id=\u0022xref-ref-2-2\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-2\u0022\u003E\u003Csup\u003E2\u003C\/sup\u003E\u003C\/a\u003E Obesity tracks from childhood to adulthood and there is emerging evidence that the precursors for diabetes and cardiovascular disease, some of which will be irreversible, already exist in obese children.\u003Ca id=\u0022xref-ref-3-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-3\u0022\u003E\u003Csup\u003E3\u2013\u003C\/sup\u003E\u003C\/a\u003E\u003Ca id=\u0022xref-ref-5-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-5\u0022\u003E\u003Csup\u003E5\u003C\/sup\u003E\u003C\/a\u003E In addition to these long term consequences on cardiovascular health being obese may be associated with psychological morbidity, though studies in this area have reported conflicting results.\u003Ca id=\u0022xref-ref-6-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-6\u0022\u003E\u003Csup\u003E6,\u003C\/sup\u003E\u003C\/a\u003E\u003Ca id=\u0022xref-ref-7-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-7\u0022\u003E\u003Csup\u003E7\u003C\/sup\u003E\u003C\/a\u003E\u003C\/p\u003E\n \u003Cp id=\u0022p-6\u0022\u003EThere is evidence going back to the 1960s that children as young as 6\u201310 years old stereotype, have negative perceptions of, and do not want to be friends with, other children who are overweight or obese.\u003Ca id=\u0022xref-ref-8-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-8\u0022\u003E\u003Csup\u003E8,\u003C\/sup\u003E\u003C\/a\u003E\u003Ca id=\u0022xref-ref-9-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-9\u0022\u003E\u003Csup\u003E9\u003C\/sup\u003E\u003C\/a\u003E Recent studies have confirmed similar findings in contemporary children.\u003Ca id=\u0022xref-ref-10-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-10\u0022\u003E\u003Csup\u003E10,\u003C\/sup\u003E\u003C\/a\u003E\u003Ca id=\u0022xref-ref-11-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-11\u0022\u003E\u003Csup\u003E11\u003C\/sup\u003E\u003C\/a\u003E Despite these findings, studies of the associations of body size with measures of psychological distress have been inconsistent,\u003Ca id=\u0022xref-ref-6-2\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-6\u0022\u003E\u003Csup\u003E6,\u003C\/sup\u003E\u003C\/a\u003E\u003Ca id=\u0022xref-ref-7-2\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-7\u0022\u003E\u003Csup\u003E7,\u003C\/sup\u003E\u003C\/a\u003E\u003Ca id=\u0022xref-ref-12-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-12\u0022\u003E\u003Csup\u003E12\u003C\/sup\u003E\u003C\/a\u003E with several reviews concluding that there is no association between body size and psychological distress.\u003Ca id=\u0022xref-ref-13-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-13\u0022\u003E\u003Csup\u003E13\u2013\u003C\/sup\u003E\u003C\/a\u003E\u003Ca id=\u0022xref-ref-15-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-15\u0022\u003E\u003Csup\u003E15\u003C\/sup\u003E\u003C\/a\u003E Others have pointed out that given the heterogeneous nature of the aetiology of both obesity and psychological distress, inconsistencies between studies are to be expected and future work should consider whether associations exist in particular groups.\u003Ca id=\u0022xref-ref-16-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-16\u0022\u003E\u003Csup\u003E16\u003C\/sup\u003E\u003C\/a\u003E For example, one might expect a gender difference in the association since females are considerably more likely than males to seek treatment for obesity (despite similar a prevalence in each gender) and there is some evidence that obesity carries more stigma in females compared to males.\u003Ca id=\u0022xref-ref-16-2\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-16\u0022\u003E\u003Csup\u003E16\u003C\/sup\u003E\u003C\/a\u003E Most studies to date have been in adult populations.\u003Ca id=\u0022xref-ref-6-3\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-6\u0022\u003E\u003Csup\u003E6,\u003C\/sup\u003E\u003C\/a\u003E\u003Ca id=\u0022xref-ref-7-3\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-7\u0022\u003E\u003Csup\u003E7\u003C\/sup\u003E\u003C\/a\u003E However, adolescents may be another group for whom body size is particularly associated with psychological distress.\u003Ca id=\u0022xref-ref-16-3\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-16\u0022\u003E\u003Csup\u003E16\u003C\/sup\u003E\u003C\/a\u003E Most studies to date, in all age groups, have been cross-sectional and therefore cannot determine whether being overweight results in psychological distress or whether this resulted in being overweight.\u003Ca id=\u0022xref-ref-12-2\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-12\u0022\u003E\u003Csup\u003E12,\u003C\/sup\u003E\u003C\/a\u003E\u003Ca id=\u0022xref-ref-16-4\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-16\u0022\u003E\u003Csup\u003E16\u003C\/sup\u003E\u003C\/a\u003E Further, cross-sectional studies cannot examine the effect of changes in overweight status over time on the occurrence of psychological outcomes.\u003C\/p\u003E\n \u003Cp id=\u0022p-7\u0022\u003EPreventing psychological distress in childhood and adolescence is important. Further, if being overweight or obese is associated with psychological distress this in turn may affect the ability of a child to respond to health promoting advice and lose weight.\u003Ca id=\u0022xref-ref-7-4\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-7\u0022\u003E\u003Csup\u003E7\u003C\/sup\u003E\u003C\/a\u003E Thus a spiral of increasing body size and distress may begin in early life. It is important therefore to determine whether being overweight or obese is associated with psychological distress in early life.\u003C\/p\u003E\n \u003Cp id=\u0022p-8\u0022\u003EThe aims of this study are to examine the associations between being overweight and behavioural problems at ages 5 and 14, to determine whether associations vary by gender, and to examine whether change in overweight status between ages 5 and 14 is associated with behavioural problems at age 14. We used the Achenbach Child Behavior Checklist (CBCL), which is a widely used, standardised, empirically based parental report instrument designed to assess behavioural problems and competencies of children aged 4\u201316 years.\u003Ca id=\u0022xref-ref-17-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-17\u0022\u003E\u003Csup\u003E17\u003C\/sup\u003E\u003C\/a\u003E The CBCL has been shown to predict future academic progress and mental distress including suicide and diagnoses of depression and psychosis.\u003Ca id=\u0022xref-ref-18-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-18\u0022\u003E\u003Csup\u003E18\u003C\/sup\u003E\u003C\/a\u003E\u003C\/p\u003E\n \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n \u003Ch2\u003EMETHODS\u003C\/h2\u003E\n \n \u003Ch3\u003EParticipants\u003C\/h3\u003E\n \u003Cp id=\u0022p-9\u0022\u003EThe Mater-University study of pregnancy and its outcomes (MUSP) is a prospective study of women, and their offspring, who received antenatal care at a major public hospital (Mater Misericordiae Hospital) in South Brisbane between 1981 and 1984.\u003Ca id=\u0022xref-ref-19-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-19\u0022\u003E\u003Csup\u003E19\u003C\/sup\u003E\u003C\/a\u003E The cohort consists of 7223 women (and their offspring) who delivered a live singleton baby, who neither died nor was adopted prior to leaving hospital, and who completed both initial phases of data collection; this represents 87% of all women who attended the antenatal clinic during the study period.\u003C\/p\u003E\n \u003Cp id=\u0022p-10\u0022\u003EThese mothers and children have been followed up prospectively with mothers completing questionnaires at their first antenatal clinic visit, 3\u20135 days after birth, 6 months after birth, 5 years, and 14 years after birth. In addition, at ages 5 and 14 detailed physical, behavioural, and developmental examinations of the children were undertaken and at 14 years the children completed health, welfare, and lifestyle questionnaires.\u003C\/p\u003E\n \n \n \u003Ch3\u003EMeasurements of exposures and outcomes\u003C\/h3\u003E\n \u003Cp id=\u0022p-11\u0022\u003EAt both ages the average of two measures of the child\u2019s weight, lightly clothed, with a scale accurate to 0.2 kg was used. Height was measured using a portable stadiometer on both occasions. Body mass index was calculated as the individual\u2019s weight in kilograms divided by the square of their height in metres. Overweight and obesity were defined according to standard definitions derived from international surveys by Cole and colleagues.\u003Ca id=\u0022xref-ref-20-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-20\u0022\u003E\u003Csup\u003E20\u003C\/sup\u003E\u003C\/a\u003E Too few of the participants fell into the obese categories for meaningful analyses (table 1) therefore we classified children as either overweight (equal to or above the overweight threshold, including those who were above the obese threshold) or normal weight (below the overweight threshold) for the main analyses presented in this paper. In this study the participants were defined as overweight at age 5 if their body mass index was greater than 17.42 kg\/m\u003Csup\u003E2\u003C\/sup\u003E for males and 17.15 kg\/m\u003Csup\u003E2\u003C\/sup\u003E for females and were defined as overweight at age 14 if their body mass index exceeded 22.62 kg\/m\u003Csup\u003E2\u003C\/sup\u003E for males and 23.34 kg\/m\u003Csup\u003E2\u003C\/sup\u003E for females. These values are equivalent to exceeding 25 kg\/m\u003Csup\u003E2\u003C\/sup\u003E in adulthood.\u003Ca id=\u0022xref-ref-20-2\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-20\u0022\u003E\u003Csup\u003E20\u003C\/sup\u003E\u003C\/a\u003E\u003C\/p\u003E\u003Cdiv class=\u0022table pos-float\u0022 id=\u0022T1\u0022\u003E\u003Cdiv class=\u0022table-inline table-callout-links\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u0022view-inline first\u0022\u003E\u003Ca href=\u0022##\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/174519\/expansion?postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022view-popup last\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/174519\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003E\n \u003Cstrong\u003ETable 1\u003C\/strong\u003E\n \u003C\/span\u003E \n \u003Cp id=\u0022p-38\u0022 class=\u0022first-child\u0022\u003E\u2003Prevalence of overweight and obesity according to adult equivalent thresholds at aged 5 and 14 among participants in the Mater-University Study of Pregnancy and its Outcomes (n\u200a=\u200a2875)\u003C\/p\u003E\n \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n \u003Cp id=\u0022p-12\u0022\u003EChild behavioural problems were assessed from maternal reports of child behaviour using modified versions of Achenbach\u2019s CBCL at ages 5 and 14.\u003Ca id=\u0022xref-ref-17-2\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-17\u0022\u003E\u003Csup\u003E17\u003C\/sup\u003E\u003C\/a\u003E The CBCL is a widely used, standardised, empirically based parental report instrument designed to assess behavioural problems and competencies of children aged 4\u201316 years.\u003Ca id=\u0022xref-ref-17-3\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-17\u0022\u003E\u003Csup\u003E17\u003C\/sup\u003E\u003C\/a\u003E Separate editions of the instrument have been standardised for both males and females aged 4\u20135, 6\u201311, and 12\u201316, and we used the sex specific 4\u20135 year old instrument at age 5 and the 12\u201316 year instrument at age 14. The CBCL has been shown in a number of studies to have construct validity and a large longitudinal study of children with at least one \u201csign of disturbance\u201d on the CBCL found high predictive value for later social, academic, emotional, and behaviour problems (including suicide and clinical neurotic and psychotic mental health diagnoses),\u003Ca id=\u0022xref-ref-18-2\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-18\u0022\u003E\u003Csup\u003E18\u003C\/sup\u003E\u003C\/a\u003E suggesting that the CBCL is a valid and reliable indicator of clinically significant psychological dysfunction. Though we recognise that our definition of behavioural problems using the CBCL is not the same as a clinical diagnosis of behavioural problems for ease of reading we refer to those with scores above the 90th centile as having behavioural problems. At age 14 the question concerning somatic behaviours was worded differently to that used originally by Achenbach. In his original questionnaire Achenbach asked about the occurrence of a number of symptoms in the following way: \u201chow often has your child had the following in the last six month, without known medical cause?\u201d; the question was followed by a list of symptoms, including, for example, dizziness, overtired, aches and pains, etc. In our version of this question the statement \u201cwithout known medical cause\u201d was omitted. In this paper we are concerned with the broad outcome of a high score on the total checklist rather than with specific responses to individual questions. However, we repeated all analyses with the response to the somatic question omitted and only other questions (relating to depression\/anxiety\/withdrawal\/aggressive behaviours\/speech problems\/sleeping difficulty) included. This allowed us to determine whether any of our results were being driven by the somatic scale, which may be less representative of psychological distress in the way that we asked it compared to Achenbach\u2019s original intention. The results from that analysis did not differ from those presented here.\u003C\/p\u003E\n \u003Cp id=\u0022p-13\u0022\u003EPubertal status was assessed using Tanner\u2019s classification.\u003Ca id=\u0022xref-ref-21-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-21\u0022\u003E\u003Csup\u003E21\u003C\/sup\u003E\u003C\/a\u003E Participants were shown pictures of breasts and genitalia representative of Tanner\u2019s classification and asked to report the best picture of their current status of development. Parental body mass indices were estimated from maternal self-report of her pre-pregnancy height and weight and that of her child\u2019s father\u2019s height and weight at the study initiation. There was a high level of correlation between maternal estimate of her pre-pregnancy weight and her measured weight on the first antenatal visit (Pearson\u2019s correlation coefficient\u200a=\u200a0.95). Maternal age at the child\u2019s birth was obtained from obstetric records and parental education was obtained from interviews with the mother at the study initiation. At the 5 and 14 year follow ups the mothers were asked to indicate gross family income for the previous year in seven pre-specified categories. In the analyses presented here these were collapsed into three categories: low, \u2a7d$AU15 599; middle, $AU15 600\u201325 999; and high, \u2a7e$AU26 000 per annum when the child was aged 5 years; and low, \u2a7d$AU25 999; middle, $AU26 000\u201336 499; and high, \u2a7e$AU36 500 per annum when the child was aged 14.\u003C\/p\u003E\n \n \n \u003Ch3\u003EStatistical analyses\u003C\/h3\u003E\n \u003Cp id=\u0022p-14\u0022\u003EMultiple logistic regression was used to assess cross-sectional and prospective associations of overweight\/obese and body mass index (as a continuous variable) with behavioural problems. In the prospective analyses those with behavioural problems at age 5 were excluded so that the association of being overweight at age 5 with the occurrence of new (incident) cases of behavioural problems could be ascertained. If those with behavioural problems at age 5 were included in these prospective analyses any associations might be explained by the persistence of behavioural problems over time rather than by our exposure of being overweight. Adjustment was made for the following potential confounding factors: age (continuous variable in days), family income (3-level categorical variable), Tanner\u2019s score of pubertal development (3-level categorical variable), maternal age at the child\u2019s birth (3-level categorical variable), parental education (3-level categorical variables), parental body mass index (continuous variable). Likelihood ratio tests were used to test for linear trends and to determine whether there was an interaction between gender and being overweight in any of the associations. Non-linear associations of body mass index with behavioural problems were assessed by including a quadratic term in the regression models. All analyses were conducted using Stata version 8.0 (Stata Inc., Texas).\u003C\/p\u003E\n \n \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-6\u0022\u003E\n \u003Ch2\u003ERESULTS\u003C\/h2\u003E\n \u003Cp id=\u0022p-15\u0022\u003EOf the 7223 participants in the original cohort, 2875 (40%) had complete data on body mass index and the behavioural checklist at both ages 5 and 14; this consisted of 1377 females and 1498 males. As reported previously loss to follow up was selective with those who did not have 5 and 14 year old follow up data being more likely to have been from low income families at the time of birth, to have had younger aged mothers at birth and mothers who smoked during their pregnancy.\u003Ca id=\u0022xref-ref-22-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-22\u0022\u003E\u003Csup\u003E22\u003C\/sup\u003E\u003C\/a\u003E All analyses in this study are based only on these 2875 with complete data. Table 1 shows the prevalence of overweight and obesity among these 2875 children together with similar prevalences for children aged 4\u20136 (used as a comparator for the MUSP children when they were aged 5) and those aged 12\u201315 (used as a comparator for the MUSP participants when they were aged 14) taken from the 1995 Australian National Nutrition Survey, a nationally representative sample.\u003Ca id=\u0022xref-ref-23-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-23\u0022\u003E\u003Csup\u003E23\u003C\/sup\u003E\u003C\/a\u003E Total prevalences of either overweight or obese were similar in our study population to those in the national survey, though there were fewer obese children in each age and sex category in our study sample. Table 2 shows the characteristics of those included in the analyses.\u003C\/p\u003E\u003Cdiv class=\u0022table pos-float\u0022 id=\u0022T2\u0022\u003E\u003Cdiv class=\u0022table-inline table-callout-links\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u0022view-inline first\u0022\u003E\u003Ca href=\u0022##\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/174527\/expansion?postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022view-popup last\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/174527\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003E\n \u003Cstrong\u003ETable 2\u003C\/strong\u003E\n \u003C\/span\u003E \n \u003Cp id=\u0022p-39\u0022 class=\u0022first-child\u0022\u003E\u2003Characteristics of study participants (n\u200a=\u200a2875)\u003C\/p\u003E\n \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n \n \u003Ch3\u003ECross-sectional associations of body mass index with behavioural problems at ages 5 and 14\u003C\/h3\u003E\n \u003Cp id=\u0022p-16\u0022\u003EIn cross-sectional analyses there was no association between being overweight and behavioural problems in either females (odds ratio 1.05; 95% CI 0.68 to 1.61) or males (1.07; 95% CI 0.68 to 1.67) at age 5. At age 14 females who were overweight were more likely than those who were normal weight to experience behavioural problems (2.10; 95% CI 1.41 to 3.14). However, there was no association between being overweight and behavioural problems at age 14 among males (1.19; 95% CI 0.81 to 1.76); p\u200a=\u200a0.004 for interaction with gender in the association between being overweight\/obese and behavioural problems.\u003C\/p\u003E\n \u003Cp id=\u0022p-17\u0022\u003EAmong female participants with complete data on all covariates (n\u200a=\u200a1245; 90% of females who were followed up and included in the main analyses presented above), the unadjusted association between being overweight and behavioural problems was 2.19 (95% CI 1.51 to 3.32), which is consistent to that presented above. With adjustment for age, pubertal stage, maternal age at birth, ethnicity, parental education, family income, and parental body mass index this attenuated to 2.03 (95% CI 1.26 to 3.25), but a positive association remained.\u003C\/p\u003E\n \u003Cp id=\u0022p-18\u0022\u003EThe prevalence of behavioural problems increased linearly across the distribution of body mass index in females at age 14 (fig 1A). No such association was seen for males at age 14 (fig 1B); p\u200a=\u200a0.01 for difference (interaction) in this linear effect between males and females. Each one standard deviation increase in body mass index at age 14 for females was associated with a 32% increased odds of behavioural problem (odds ratio 1.32; 95% CI 1.08 to 1.61) with full adjustment. In males the fully adjusted odds ratio of behavioural problems for a one standard deviation increase in body mass index was 1.06 (95% CI 0.88 to 1.29); p\u200a=\u200a0.18 for interaction with gender in these models. When quadratic terms were added to these models there was no evidence of non-linear associations in either sex (p \u0026gt; 0.4 for both).\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022https:\/\/adc.bmj.com\/content\/archdischild\/90\/7\/692\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022\u0026#x2003;Unadjusted prevalence of behavioural problems by fifths of body mass index distribution among (A) females and (B) males aged 14.\u0022 class=\u0022highwire-fragment fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1261181976\u0022 data-figure-caption=\u0022\u0026lt;div class=\u0026quot;highwire-markup\u0026quot;\u0026gt;\u0026#x2003;Unadjusted prevalence of behavioural problems by fifths of body mass index distribution among (A) females and (B) males aged 14.\u0026lt;\/div\u0026gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cspan class=\u0022hw-responsive-img\u0022\u003E\u003Cimg class=\u0022highwire-fragment fragment-image lazyload\u0022 alt=\u0022 Figure 1 \u0022 src=\u0022data:image\/gif;base64,R0lGODlhAQABAIAAAAAAAP\/\/\/yH5BAEAAAAALAAAAAABAAEAAAIBRAA7\u0022 data-src=\u0022https:\/\/adc.bmj.com\/content\/archdischild\/90\/7\/692\/F1.medium.gif\u0022 width=\u0022289\u0022 height=\u0022440\u0022\/\u003E\u003Cnoscript\u003E\u003Cimg class=\u0022highwire-fragment fragment-image\u0022 alt=\u0022 Figure 1 \u0022 src=\u0022https:\/\/adc.bmj.com\/content\/archdischild\/90\/7\/692\/F1.medium.gif\u0022 width=\u0022289\u0022 height=\u0022440\u0022\/\u003E\u003C\/noscript\u003E\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u0022download-fig first\u0022\u003E\u003Ca href=\u0022https:\/\/adc.bmj.com\/content\/archdischild\/90\/7\/692\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1 \u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022new-tab\u0022\u003E\u003Ca href=\u0022https:\/\/adc.bmj.com\/content\/archdischild\/90\/7\/692\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022download-ppt last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/174509\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003E\n \u003Cstrong\u003EFigure 1\u003C\/strong\u003E\n \u003C\/span\u003E \n \u003Cp id=\u0022p-41\u0022 class=\u0022first-child\u0022\u003E\u2003Unadjusted prevalence of behavioural problems by fifths of body mass index distribution among (A) females and (B) males aged 14.\u003C\/p\u003E\n \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n \n \n \u003Ch3\u003EProspective associations of body mass index at age 5 and behavioural problems at age 14\u003C\/h3\u003E\n \u003Cp id=\u0022p-19\u0022\u003EAmong participants who had no behavioural problems at age 5 there were no associations between being overweight at age 5 in either sex, and behavioural problems and age 14 and body mass index at age 5 entered into models as a continuous variable were not associated with behavioural problems at age 14 in either sex (all p \u0026gt; 0.5).\u003C\/p\u003E\n \u003Cp id=\u0022p-20\u0022\u003ETable 3 shows the cumulative association of being overweight at ages 5 and 14 with behavioural problems at age 5 among those who had no behavioural problems at age 5. Although imprecise among females, those who were overweight at age 5 and normal weight at age 14, compared to those who were normal weight at both ages tended to have reduced odds of behavioural problems. As expected from the cross-sectional analyses, those who were normal weight at age 5 and overweight at age 14 and those who were overweight at both ages had increased odds of behavioural problems at age 14. Among males the odds of behavioural problems were somewhat lower among those who were overweight at age 5 but then normal weight at age 14, but in general the odds ratios were similar for each category of overweight status at the two ages in males.\u003C\/p\u003E\u003Cdiv class=\u0022table pos-float\u0022 id=\u0022T3\u0022\u003E\u003Cdiv class=\u0022table-inline table-callout-links\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u0022view-inline first\u0022\u003E\u003Ca href=\u0022##\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/174534\/expansion?postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\n\u003Cli class=\u0022view-popup last\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/174534\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\n\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003E\n \u003Cstrong\u003ETable 3\u003C\/strong\u003E\n \u003C\/span\u003E \n \u003Cp id=\u0022p-40\u0022 class=\u0022first-child\u0022\u003E\u2003Association of overweight status at ages 5 and 14 with behavioural problems at age 14 among those free of behavioural problems at age 5 and with complete data on all covariates (n\u200a=\u200a2430)\u003C\/p\u003E\n \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n \n \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-9\u0022\u003E\n \u003Ch2\u003EDISCUSSION\u003C\/h2\u003E\n \u003Cp id=\u0022p-21\u0022\u003EWe have found in cross-sectional analyses that females who are overweight at age 14 have increased odds of behavioural problems compared to those who are not overweight. Further, there was a linear trend of increasing behavioural problems with increasing body mass index across the distribution of body mass index. This positive linear association between body mass index and behavioural problems among females was independent of a range of potential confounding. We found no evidence of an association between being overweight and behavioural problems at age 5 and no clear associations in males. In prospective analyses being overweight at age 5 was not associated with behavioural problems at age 14 in either sex. For females there was some suggestion that in those who had been overweight at age 5 and then normal weight at age 14, behavioural problems were less likely than in those who were overweight at both ages. This may reflect a positive psychological response to relative weight loss among females. However, since this estimate was imprecise, further work, in larger studies, is required to confirm this finding. The lack of an association in prospective analyses may be because cross-sectional associations are due to reverse causality, with poor psychological adjustment resulting in weight gain. Alternatively the 9 year gap between age 5 and 14 may be too long to establish a causal association with an effect over a shorter duration.\u003C\/p\u003E\n \u003Cp id=\u0022p-22\u0022\u003EA number of related mechanisms might explain the link between being overweight and behavioural problems among adolescent females, including stigmatisation and the response to negative perceptions from one\u2019s peers, and body dissatisfaction related not only to peers but to a wider perception of acceptable appearance.\u003Ca id=\u0022xref-ref-2-3\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-2\u0022\u003E\u003Csup\u003E2\u003C\/sup\u003E\u003C\/a\u003E If the effect of being overweight on behavioural problems were related to stigmatisation and negative perceptions from one\u2019s peers, then this effect may diminish relatively quickly over time once the child had lost weight. Body dissatisfaction, which is often described as \u201cnormative\u201d among women in contemporary western society, particularly among adolescent and young adult samples,\u003Ca id=\u0022xref-ref-24-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-24\u0022\u003E\u003Csup\u003E24\u2013\u003C\/sup\u003E\u003C\/a\u003E\u003Ca id=\u0022xref-ref-26-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-26\u0022\u003E\u003Csup\u003E26\u003C\/sup\u003E\u003C\/a\u003E is more prevalent among those who are overweight.\u003Ca id=\u0022xref-ref-27-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-27\u0022\u003E\u003Csup\u003E27\u003C\/sup\u003E\u003C\/a\u003E The longer a female has been overweight the worse her body dissatisfaction tends to be,\u003Ca id=\u0022xref-ref-27-2\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-27\u0022\u003E\u003Csup\u003E27\u003C\/sup\u003E\u003C\/a\u003E and a study among obese adults found that those who were obese by age 16 years, compared to those whose obesity developed at a later age, were more likely to experience body dissatisfaction and low self esteem in adulthood.\u003Ca id=\u0022xref-ref-28-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-28\u0022\u003E\u003Csup\u003E28\u003C\/sup\u003E\u003C\/a\u003E However, body dissatisfaction tends to emerge in late childhood and adolescence,\u003Ca id=\u0022xref-ref-24-2\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-24\u0022\u003E\u003Csup\u003E24\u2013\u003C\/sup\u003E\u003C\/a\u003E\u003Ca id=\u0022xref-ref-26-2\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-26\u0022\u003E\u003Csup\u003E26\u003C\/sup\u003E\u003C\/a\u003E and therefore being overweight at age 5 may not be related to body dissatisfaction to the same degree a being overweight at an older age.\u003C\/p\u003E\n \n \u003Ch3\u003EStudy limitations\u003C\/h3\u003E\n \u003Cp id=\u0022p-23\u0022\u003EData on body mass index and behavioural problems at ages 5 and 14 were only available on 40% of the original cohort, and those without these data were more likely to be from poorer family backgrounds, have younger mothers, and have mothers who smoked throughout their pregnancy.\u003Ca id=\u0022xref-ref-22-2\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-22\u0022\u003E\u003Csup\u003E22\u003C\/sup\u003E\u003C\/a\u003E Despite this loss to follow up, the prevalence of overweight or obesity in this sample was consistent with national data (table 1). The slightly lower prevalence of obesity in each age and sex category in this sample compared to the national sample may be due to the more obese children being lost to follow up in our sample or may reflect geographical or temporal variations. Our results would only be biased if the associations we have presented here were either non-existent or in the opposite direction among those who were not examined at ages 5 and 14. That is to say, among the non-responders one would need to imagine that overweight females had reduced, or similar, odds of behavioural problems to those who were not overweight for our results to be biased. While we cannot rule out this possibility it seems unlikely. Our assessment of Tanner\u2019s pubertal stage was not done by trained professionals but was done by asking the participants to rate their own secondary sexual characteristics against pictorial representations of Tanner\u2019s scale. This may be inaccurate and may therefore mean that we have not fully adjusted for pubertal status in our associations.\u003C\/p\u003E\n \u003Cp id=\u0022p-24\u0022\u003EWe attempted to determine the causal direction of the association by assessing the association of overweight status at age 5 with behavioural problems at age 14 and found no association. However, since the time between the two follow up periods covers nine years we cannot rule out the possibility that with a shorter period of follow up a positive association may have been detected. A prospective study in adults aged 46 years and older found that obesity was associated with subsequent depression over a follow up period of one year.\u003Ca id=\u0022xref-ref-29-1\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-29\u0022\u003E\u003Csup\u003E29\u003C\/sup\u003E\u003C\/a\u003E Had we data on shorter periods of follow up we may have found a prospective association.\u003C\/p\u003E\n \u003Cp id=\u0022p-25\u0022\u003EAlthough our cross-sectional analyses suggest that body mass index is not associated with behavioural problems in early childhood, since we only have information at two time points\u2014when the children were aged 5 years and 14 years\u2014it is impossible to determine from this study at what age among females the associations between being overweight and behavioural problems first develop.\u003C\/p\u003E\n \n \n \u003Ch3\u003EImplications\u003C\/h3\u003E\n \u003Cp id=\u0022p-26\u0022\u003EAlthough much concern has been expressed about the epidemic of obesity among children and adolescents with respect to the consequences that this has for future development of diabetes and cardiovascular disease, at the actual time of adolescence psychological problems may be one of the main health consequence of overweight or obesity.\u003Ca id=\u0022xref-ref-1-3\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-1\u0022\u003E\u003Csup\u003E1\u003C\/sup\u003E\u003C\/a\u003E Previous studies, which have reported inconsistent results, have largely been in adult populations, have rarely formally assessed whether associations differ between females and males (despite plausible reasons for them doing so) and have largely been cross-sectional.\u003Ca id=\u0022xref-ref-7-5\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-7\u0022\u003E\u003Csup\u003E7,\u003C\/sup\u003E\u003C\/a\u003E\u003Ca id=\u0022xref-ref-12-3\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-12\u0022\u003E\u003Csup\u003E12,\u003C\/sup\u003E\u003C\/a\u003E\u003Ca id=\u0022xref-ref-16-5\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-16\u0022\u003E\u003Csup\u003E16\u003C\/sup\u003E\u003C\/a\u003E Our findings add to this previous work by examining associations in childhood and adolescence, determining whether there is statistical evidence for gender differences in any associations and examining the association prospectively. \u003C\/p\u003E\n \u003Cp id=\u0022p-27\u0022\u003EAlthough our results cannot determine with certainty whether the cross-sectional association among females at age 14 is largely due to being overweight leading to psychological distress or vice versa, it is important in clinical practice to acknowledge this association (irrespective of its causal direction). Psychological distress may have a negative impact on weight reduction interventions aimed at adolescents who are overweight or obese, and may as a consequence prevent weight loss and hence increase the future risk of chronic diseases associated with being overweight or obese.\u003Ca id=\u0022xref-ref-7-6\u0022 class=\u0022xref-ref\u0022 href=\u0022#ref-7\u0022\u003E\u003Csup\u003E7\u003C\/sup\u003E\u003C\/a\u003E These findings suggest that psychological distress should be considered as a co-morbidity of overweight at this age and that programmes aimed at weight reduction in adolescence need to incorporate elements that deal with psychological symptoms.\u003C\/p\u003E\n \u003Cp id=\u0022p-28\u0022\u003E\n \u003Cdiv class=\u0022boxed-text\u0022 id=\u0022boxed-text-1\u0022\u003E\n \u003Ch3\u003E\u003Cstrong\u003EWhat is already known on this topic\u003C\/strong\u003E\u003C\/h3\u003E\n \u003Cp\u003E\n \u003C\/p\u003E\u003Cul class=\u0022list-unord\u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n \u003Cp id=\u0022p-30\u0022\u003EEvidence regarding the association of being overweight with psychological distress in children and adolescents is unclear\u003C\/p\u003E\n \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n \u003C\/p\u003E\n \u003C\/div\u003E\n \u003C\/p\u003E\n \u003Cp id=\u0022p-31\u0022\u003EIn our study we found no association between body mass index and behavioural problems among males. However, this does not necessarily mean that body image is not an important concern for males. Rather it is more likely that striving for different body ideals that are not described by body mass index, such as broad chests and muscular appearance, is a potential source of distress among males.\u003C\/p\u003E\n \u003Cp id=\u0022p-32\u0022\u003EWe suggest that further work in this area should examine prospective associations between body size and behavioural problems measured at repeated short intervals over time in large population samples of children and adolescents.\u003C\/p\u003E\n \u003Cp id=\u0022p-33\u0022\u003E\n \u003Cdiv class=\u0022boxed-text\u0022 id=\u0022boxed-text-2\u0022\u003E\n \u003Ch3\u003E\u003Cstrong\u003EWhat this study adds\u003C\/strong\u003E\u003C\/h3\u003E\n \u003Cp\u003E\n \u003C\/p\u003E\u003Cul class=\u0022list-unord\u0022 id=\u0022list-2\u0022\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n \u003Cp id=\u0022p-35\u0022\u003EAmong females, but not males, there is a graded linear association between body mass index and behavioural problems at age 14\u003C\/p\u003E\n \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n \u003Cp id=\u0022p-36\u0022\u003EThere is no association between body mass index and behavioural problems at age 5 in either sex\u003C\/p\u003E\n \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n \u003Cp id=\u0022p-37\u0022\u003EIn prospective analyses, body mass index at age 5 was not associated with behavioural problems at age 14\u003C\/p\u003E\n \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n \u003C\/p\u003E\n \u003C\/div\u003E\n \u003C\/p\u003E\n \n \u003C\/div\u003E\u003Cdiv class=\u0022section ack\u0022 id=\u0022ack-1\u0022\u003E\u003Ch2\u003EAcknowledgments\u003C\/h2\u003E\n \u003Cp id=\u0022p-44\u0022\u003EWe are grateful to all participants in the study. Greg Shuttlewood, University of Queensland, helped with data management for the study.\u003C\/p\u003E\n \u003C\/div\u003E\u003Cdiv class=\u0022section ref-list\u0022 id=\u0022ref-list-1\u0022\u003E\u003Ch2\u003EREFERENCES\u003C\/h2\u003E\u003Col class=\u0022cit-list\u0022\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-1-1\u0022 title=\u0022View reference 1 in text\u0022 id=\u0022ref-1\u0022\u003E\u21b5\u003C\/a\u003E\n \n \u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-90.7.692.1\u0022 data-doi=\u002210.1016\/S0140-6736(02)09678-2\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003E\u003Cstrong\u003EEbbeling CB\u003C\/strong\u003E, Pawlak DB, Ludwig DS. 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Obesity in children and young people: a crisis in public health. \u003Cspan class=\u0022cit-source\u0022\u003EObes Rev\u003C\/span\u003E\u003Cspan class=\u0022cit-pub-date\u0022\u003E2004\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E5\u003C\/span\u003E (suppl 1) :\u003Cspan class=\u0022cit-fpage\u0022\u003E4\u003C\/span\u003E\u201385.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\n \u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-3-1\u0022 title=\u0022View reference 3 in text\u0022 id=\u0022ref-3\u0022\u003E\u21b5\u003C\/a\u003E\n \n \u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-90.7.692.3\u0022 data-doi=\u002210.2337\/diabetes.51.1.204\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003E\u003Cstrong\u003ESrinivasan SR\u003C\/strong\u003E, Myers L, Berenson GS. Predictability of childhood adiposity and insulin for developing insulin resistance syndrome (syndrome X) in young adulthood: the Bogalusa Heart Study. \u003Cspan class=\u0022cit-source\u0022\u003EDiabetes\u003C\/span\u003E\u003Cspan class=\u0022cit-pub-date\u0022\u003E2002\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E51\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E204\u003C\/span\u003E\u20139.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca 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New York: Guildford, \u003Cspan class=\u0022cit-pub-date\u0022\u003E1995\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E417\u003C\/span\u003E\u201321.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\n \u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-7-1\u0022 title=\u0022View reference 7 in text\u0022 id=\u0022ref-7\u0022\u003E\u21b5\u003C\/a\u003E\n \n \u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-90.7.692.7\u0022 data-doi=\u002210.1097\/00004583-200402000-00008\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003E\u003Cstrong\u003EZametkin AJ\u003C\/strong\u003E, Zoon CK, Klein HW, \u003Cem\u003Eet al.\u003C\/em\u003E Psychiatric aspects of child and adolescent obesity: a review of the past 10 years. \u003Cspan class=\u0022cit-source\u0022\u003EJ Am Acad Child Adolesc Psychiatry\u003C\/span\u003E\u003Cspan class=\u0022cit-pub-date\u0022\u003E2004\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E43\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E134\u003C\/span\u003E\u201350.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DJournal%2Bof%2Bthe%2BAmerican%2BAcademy%2Bof%2BChild%2Band%2BAdolescent%2BPsychiatry%26rft.stitle%253DJ%2BAm%2BAcad%2BChild%2BAdolesc%2BPsychiatry%26rft.aulast%253DZametkin%26rft.auinit1%253DA.%2BJ.%26rft.volume%253D43%26rft.issue%253D2%26rft.spage%253D134%26rft.epage%253D150%26rft.atitle%253DPsychiatric%2Baspects%2Bof%2Bchild%2Band%2Badolescent%2Bobesity%253A%2Ba%2Breview%2Bof%2Bthe%2Bpast%2B10%2Byears.%26rft_id%253Dinfo%253Adoi%252F10.1097%252F00004583-200402000-00008%26rft_id%253Dinfo%253Apmid%252F14726719%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=10.1097\/00004583-200402000-00008\u0026amp;link_type=DOI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref\u0022\u003E\u003Cspan\u003ECrossRef\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=14726719\u0026amp;link_type=MED\u0026amp;atom=%2Farchdischild%2F90%2F7%2F692.atom\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-medline\u0022\u003E\u003Cspan\u003EPubMed\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=000188289500008\u0026amp;link_type=ISI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-newisilink cit-ref-sprinkles-webofscience\u0022\u003E\u003Cspan\u003EWeb of Science\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\n \u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-8-1\u0022 title=\u0022View reference 8 in text\u0022 id=\u0022ref-8\u0022\u003E\u21b5\u003C\/a\u003E\n \n \u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-90.7.692.8\u0022 data-doi=\u002210.1037\/h0021227\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003E\u003Cstrong\u003EStaffieri JR\u003C\/strong\u003E. 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href=\u0022{openurl}?query=rft.jtitle%253DBMJ%26rft.stitle%253DBMJ%26rft.issn%253D0007-1447%26rft.aulast%253DCole%26rft.auinit1%253DT.%2BJ%26rft.volume%253D320%26rft.issue%253D7244%26rft.spage%253D1240%26rft.epage%253D1240%26rft.atitle%253DEstablishing%2Ba%2Bstandard%2Bdefinition%2Bfor%2Bchild%2Boverweight%2Band%2Bobesity%2Bworldwide%253A%2Binternational%2Bsurvey%26rft_id%253Dinfo%253Adoi%252F10.1136%252Fbmj.320.7244.1240%26rft_id%253Dinfo%253Apmid%252F10797032%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca 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Oxford: Blackwell, \u003Cspan class=\u0022cit-pub-date\u0022\u003E1962\u003C\/span\u003E.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\n \u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-22-1\u0022 title=\u0022View reference 22 in text\u0022 id=\u0022ref-22\u0022\u003E\u21b5\u003C\/a\u003E\n \n \u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-90.7.692.22\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003E\u003Cstrong\u003ENajman JM\u003C\/strong\u003E, Aird R, Bor W, \u003Cem\u003Eet al.\u003C\/em\u003E The generational transmission of socioeconomic inequalities in child cognitive development and emotional health. \u003Cspan class=\u0022cit-source\u0022\u003ESoc Sci Med\u003C\/span\u003E\u003Cspan class=\u0022cit-pub-date\u0022\u003E2004\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E58\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E1147\u003C\/span\u003E\u201358.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\n \u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-23-1\u0022 title=\u0022View reference 23 in text\u0022 id=\u0022ref-23\u0022\u003E\u21b5\u003C\/a\u003E\n \n \u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-90.7.692.23\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003E\u003Cstrong\u003EMagarey AM\u003C\/strong\u003E, Daniels LA, Boulton TJ. Prevalence of overweight and obesity in Australian children and adolescents: reassessment of 1985 and 1995 data against new standard international definitions. \u003Cspan class=\u0022cit-source\u0022\u003EMed J Aust\u003C\/span\u003E\u003Cspan class=\u0022cit-pub-date\u0022\u003E2001\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E174\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E561\u003C\/span\u003E\u20134.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DMedical%2BJournal%2Bof%2BAustralia%26rft.stitle%253DMedical%2BJournal%2Bof%2BAustralia%26rft.aulast%253DMagarey%26rft.auinit1%253DA.%2BM.%26rft.volume%253D174%26rft.issue%253D11%26rft.spage%253D561%26rft.epage%253D564%26rft.atitle%253DPrevalence%2Bof%2Boverweight%2Band%2Bobesity%2Bin%2BAustralian%2Bchildren%2Band%2Badolescents%253A%2Breassessment%2Bof%2B1985%2Band%2B1995%2Bdata%2Bagainst%2Bnew%2Bstandard%2Binternational%2Bdefinitions.%26rft_id%253Dinfo%253Apmid%252F11453327%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=11453327\u0026amp;link_type=MED\u0026amp;atom=%2Farchdischild%2F90%2F7%2F692.atom\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-medline\u0022\u003E\u003Cspan\u003EPubMed\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=000169075300006\u0026amp;link_type=ISI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-newisilink cit-ref-sprinkles-webofscience\u0022\u003E\u003Cspan\u003EWeb of Science\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\n \u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-24-1\u0022 title=\u0022View reference 24 in text\u0022 id=\u0022ref-24\u0022\u003E\u21b5\u003C\/a\u003E\n \n \u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-90.7.692.24\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003E\u003Cstrong\u003EWardle J\u003C\/strong\u003E, Beales S. Restraint, body image and food attitudes in children from 12 to 18 years. \u003Cspan class=\u0022cit-source\u0022\u003EAppetite\u003C\/span\u003E\u003Cspan class=\u0022cit-pub-date\u0022\u003E1986\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E7\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E209\u003C\/span\u003E\u201317.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DAppetite%26rft.stitle%253DAppetite%26rft.aulast%253DWardle%26rft.auinit1%253DJ.%26rft.volume%253D7%26rft.issue%253D3%26rft.spage%253D209%26rft.epage%253D217%26rft.atitle%253DRestraint%252C%2Bbody%2Bimage%2Band%2Bfood%2Battitudes%2Bin%2Bchildren%2Bfrom%2B12%2Bto%2B18%2Byears.%26rft_id%253Dinfo%253Apmid%252F3800362%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=3800362\u0026amp;link_type=MED\u0026amp;atom=%2Farchdischild%2F90%2F7%2F692.atom\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-medline\u0022\u003E\u003Cspan\u003EPubMed\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=A1986E213900002\u0026amp;link_type=ISI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-newisilink cit-ref-sprinkles-webofscience\u0022\u003E\u003Cspan\u003EWeb of Science\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\n \u003C\/li\u003E\u003Cli\u003E\n \n \u003Cdiv class=\u0022cit ref-cit ref-other no-rev-xref\u0022 id=\u0022cit-90.7.692.25\u0022 data-doi=\u002210.1017\/S0021963097001807\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003E\u003Cstrong\u003EKostanski M\u003C\/strong\u003E, Gullone E. Adolescent body image dissatisfaction: relationships with self-esteem, anxiety, and depression controlling for body mass. \u003Cspan class=\u0022cit-source\u0022\u003EJ Child Psychol Psychiatry\u003C\/span\u003E\u003Cspan class=\u0022cit-pub-date\u0022\u003E1998\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E39\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E255\u003C\/span\u003E\u201362.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DJournal%2Bof%2Bchild%2Bpsychology%2Band%2Bpsychiatry%252C%2Band%2Ballied%2Bdisciplines%26rft.stitle%253DJ%2BChild%2BPsychol%2BPsychiatry%26rft.aulast%253DKostanski%26rft.auinit1%253DM.%26rft.volume%253D39%26rft.issue%253D2%26rft.spage%253D255%26rft.epage%253D262%26rft.atitle%253DAdolescent%2Bbody%2Bimage%2Bdissatisfaction%253A%2Brelationships%2Bwith%2Bself-esteem%252C%2Banxiety%252C%2Band%2Bdepression%2Bcontrolling%2Bfor%2Bbody%2Bmass.%26rft_id%253Dinfo%253Adoi%252F10.1017%252FS0021963097001807%26rft_id%253Dinfo%253Apmid%252F9669238%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=10.1017\/S0021963097001807\u0026amp;link_type=DOI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref\u0022\u003E\u003Cspan\u003ECrossRef\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=9669238\u0026amp;link_type=MED\u0026amp;atom=%2Farchdischild%2F90%2F7%2F692.atom\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-medline\u0022\u003E\u003Cspan\u003EPubMed\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=000072195700013\u0026amp;link_type=ISI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-newisilink cit-ref-sprinkles-webofscience\u0022\u003E\u003Cspan\u003EWeb of Science\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\n \u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-26-1\u0022 title=\u0022View reference 26 in text\u0022 id=\u0022ref-26\u0022\u003E\u21b5\u003C\/a\u003E\n \n \u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-90.7.692.26\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003E\u003Cstrong\u003ETiggemann M \u003C\/strong\u003E. Body-size dissatisfaction: individual differences in age and gender, and relationship with self-esteem. \u003Cspan class=\u0022cit-source\u0022\u003EPersonality and Individual Differences\u003C\/span\u003E\u003Cspan class=\u0022cit-pub-date\u0022\u003E1992\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E13\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E39\u003C\/span\u003E\u201343.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\n \u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-27-1\u0022 title=\u0022View reference 27 in text\u0022 id=\u0022ref-27\u0022\u003E\u21b5\u003C\/a\u003E\n \n \u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-90.7.692.27\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003E\u003Cstrong\u003EMcLaren L\u003C\/strong\u003E, Gauvin L. The cumulative impact of being overweight on women\u2019s body esteem: a preliminary study. \u003Cspan class=\u0022cit-source\u0022\u003EEat Weight Disord\u003C\/span\u003E\u003Cspan class=\u0022cit-pub-date\u0022\u003E2002\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E7\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E324\u003C\/span\u003E\u20137.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DEating%2Band%2BWeight%2BDisorders%2B%2528Printed%2BText%2529%26rft.stitle%253DEating%2Band%2BWeight%2BDisorders%2B%2528Printed%2BText%2529%26rft.aulast%253DMcLaren%26rft.auinit1%253DL.%26rft.volume%253D7%26rft.issue%253D4%26rft.spage%253D324%26rft.epage%253D327%26rft.atitle%253DThe%2Bcumulative%2Bimpact%2Bof%2Bbeing%2Boverweight%2Bon%2Bwomen%2527s%2Bbody%2Besteem%253A%2Ba%2Bpreliminary%2Bstudy.%26rft_id%253Dinfo%253Apmid%252F12588062%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=12588062\u0026amp;link_type=MED\u0026amp;atom=%2Farchdischild%2F90%2F7%2F692.atom\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-medline\u0022\u003E\u003Cspan\u003EPubMed\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\n \u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-28-1\u0022 title=\u0022View reference 28 in text\u0022 id=\u0022ref-28\u0022\u003E\u21b5\u003C\/a\u003E\n \n \u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-90.7.692.28\u0022 data-doi=\u002210.1016\/S0306-4603(01)00193-9\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003E\u003Cstrong\u003EWardle J\u003C\/strong\u003E, Waller J, Fox E. Age of onset and body dissatisfaction in obesity. \u003Cspan class=\u0022cit-source\u0022\u003EAddict Behav\u003C\/span\u003E\u003Cspan class=\u0022cit-pub-date\u0022\u003E2002\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E27\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E561\u003C\/span\u003E\u201373.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DAddictive%2Bbehaviors%26rft.stitle%253DAddict%2BBehav%26rft.aulast%253DWardle%26rft.auinit1%253DJ.%26rft.volume%253D27%26rft.issue%253D4%26rft.spage%253D561%26rft.epage%253D573%26rft.atitle%253DAge%2Bof%2Bonset%2Band%2Bbody%2Bdissatisfaction%2Bin%2Bobesity.%26rft_id%253Dinfo%253Adoi%252F10.1016%252FS0306-4603%252801%252900193-9%26rft_id%253Dinfo%253Apmid%252F12188592%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=10.1016\/S0306-4603(01)00193-9\u0026amp;link_type=DOI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref\u0022\u003E\u003Cspan\u003ECrossRef\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=12188592\u0026amp;link_type=MED\u0026amp;atom=%2Farchdischild%2F90%2F7%2F692.atom\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-medline\u0022\u003E\u003Cspan\u003EPubMed\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/external-ref?access_num=000177463600007\u0026amp;link_type=ISI\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-newisilink cit-ref-sprinkles-webofscience\u0022\u003E\u003Cspan\u003EWeb of Science\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\n \u003C\/li\u003E\u003Cli\u003E\u003Ca class=\u0022rev-xref-ref\u0022 href=\u0022#xref-ref-29-1\u0022 title=\u0022View reference 29 in text\u0022 id=\u0022ref-29\u0022\u003E\u21b5\u003C\/a\u003E\n \n \u003Cdiv class=\u0022cit ref-cit ref-other\u0022 id=\u0022cit-90.7.692.29\u0022 data-doi=\u002210.1093\/aje\/152.2.163\u0022\u003E\u003Cdiv class=\u0022cit-metadata\u0022\u003E\u003Ccite\u003E\u003Cstrong\u003ERoberts RE\u003C\/strong\u003E, Kaplan GA, Shema SJ, Strawbridge WJ. Are the obese at greater risk for depression? \u003Cspan class=\u0022cit-source\u0022\u003EAm J Epidemiol\u003C\/span\u003E\u003Cspan class=\u0022cit-pub-date\u0022\u003E2000\u003C\/span\u003E;\u003Cspan class=\u0022cit-vol\u0022\u003E152\u003C\/span\u003E:\u003Cspan class=\u0022cit-fpage\u0022\u003E163\u003C\/span\u003E\u201370.\u003C\/cite\u003E\u003C\/div\u003E\u003Cdiv class=\u0022cit-extra\u0022\u003E\u003Ca href=\u0022{openurl}?query=rft.jtitle%253DAmerican%2BJournal%2Bof%2BEpidemiology%26rft.stitle%253DAm%2BJ%2BEpidemiol%26rft.issn%253D0002-9262%26rft.aulast%253DRoberts%26rft.auinit1%253DR.%2BE.%26rft.volume%253D152%26rft.issue%253D2%26rft.spage%253D163%26rft.epage%253D170%26rft.atitle%253DAre%2Bthe%2BObese%2Bat%2BGreater%2BRisk%2Bfor%2BDepression%253F%26rft_id%253Dinfo%253Adoi%252F10.1093%252Faje%252F152.2.163%26rft_id%253Dinfo%253Apmid%252F10909953%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-openurl cit-ref-sprinkles-open-url\u0022\u003E\u003Cspan\u003EOpenUrl\u003C\/span\u003E\u003C\/a\u003E\u003Ca href=\u0022\/lookup\/ijlink\/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NzoiYW1qZXBpZCI7czo1OiJyZXNpZCI7czo5OiIxNTIvMi8xNjMiO3M6NDoiYXRvbSI7czoyNzoiL2FyY2hkaXNjaGlsZC85MC83LzY5Mi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=\u0022 class=\u0022cit-ref-sprinkles cit-ref-sprinkles-ijlink\u0022\u003E\u003Cspan\u003E\u003Cspan class=\u0022cit-reflinks-abstract\u0022\u003EAbstract\u003C\/span\u003E\u003Cspan class=\u0022cit-sep cit-reflinks-variant-name-sep\u0022\u003E\/\u003C\/span\u003E\u003Cspan class=\u0022cit-reflinks-full-text\u0022\u003E\u003Cspan class=\u0022free-full-text\u0022\u003EFREE \u003C\/span\u003EFull Text\u003C\/span\u003E\u003C\/span\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\n \u003C\/li\u003E\u003C\/ol\u003E\u003C\/div\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022https:\/\/adc.bmj.com\/content\/90\/7\/692.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Abstract\u003C\/a\u003E\u003C\/div\u003E \u003C\/div\u003E\n\n \n \u003C\/div\u003E\n\u003Cdiv class=\u0022panel-separator\u0022\u003E\u003C\/div\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup footnotes\u0022 \u003E\n \n \n \n \u003Cdiv class=\u0022pane-content\u0022\u003E\n \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 class=\u0022section fn-group\u0022 id=\u0022fn-group-1\u0022\u003E\u003Ch2\u003EFootnotes\u003C\/h2\u003E\u003Cul\u003E\u003Cli class=\u0022fn\u0022 id=\u0022fn-1\u0022\u003E\n \u003Cp id=\u0022p-42\u0022\u003EFunding: The core study was funded by the National Health and Medical Research Council (NHMRC) of Australia. This work was funded by the NHMRC (grant number: 252834) and carried out at The University of Queensland and The Mater Hospital. DAL is funded by a (UK) Department of Health Career Scientist Award. 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